subclinical hypothyroid
Download
Skip this Video
Download Presentation
SUBCLINICAL HYPOTHYROID

Loading in 2 Seconds...

play fullscreen
1 / 79

SUBCLINICAL HYPOTHYROID - PowerPoint PPT Presentation


  • 443 Views
  • Uploaded on

SUBCLINICAL HYPOTHYROID. MANAGING PATIENTS USING RESTING METABOLIC RATE AND BRACHIORADIALIS REFLEXOMETRY Dr. Konrad Kail 480-905-9200 [email protected] GENERAL CONSIDERATIONS. MUST WORK FOR HUMANS TO FUNCTION ABSORPTION AND ASSIMILATION DETOXIFICATION AND ELIMINATION REGULATION

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'SUBCLINICAL HYPOTHYROID ' - PamelaLan


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
subclinical hypothyroid

SUBCLINICAL HYPOTHYROID

MANAGING PATIENTS USING

RESTING METABOLIC RATE

AND

BRACHIORADIALIS REFLEXOMETRY

Dr. Konrad Kail

480-905-9200

[email protected]

general considerations
GENERAL CONSIDERATIONS
  • MUST WORK FOR HUMANS TO FUNCTION
    • ABSORPTION AND ASSIMILATION
    • DETOXIFICATION AND ELIMINATION
    • REGULATION
  • STRESS IMPACTS ALL OF THESE BUT THE MOST PROFOUND AND IMMEDIATE EFFECT IS ON REGULATION
    • ADRENAL AND THYROID GLANDS ARE THE MOST STRESS LABILE
  • ADRENAL AND THYROID INTERACT IN REGULATING
    • WEIGHT
    • ENERGY
    • BLOOD SUGAR
    • BLOOD FATS
    • NEUROTRANSMITTERS
    • SEX HORMONES
    • INFLAMMATION
    • IMMUNE FUNCTION
organ reserve
ORGAN RESERVE

SUPPORT

ORGAN

RESERVE

Degeneration

STRESSORS

thyroid feedback regulation
The production of thyroid hormone is controlled by a feedback loop. When there is not enough receptor site activity in the hypothalamus, TRH is elaborated which stimulates the anterior pituitary to make TSH, which then stimulates the thyroid to make more T3 and T4.

The thyroid gland uses

L-Tyrosine and Iodine to make T4, the storage form of thyroid hormone and T3 the active form

Thyroid Feedback Regulation
subclinical hypothyroid5
SUBCLINICAL HYPOTHYROID
  • SYMPTOMS COMPATIBLE WITH HYPOTHYROID (> 12 on Symptom Survey)
  • LOW BBT (< 97.5o F axillary)
  • SLOW REFLEXES (> 137 msecs)
  • LOWER RMR
  • NORMAL TO SLIGHTLY HIGH TSH
  • NORMAL FREE T3, FREE T4
  • NORMAL T3U, T4, T7
  • PREVALENCE UNKNOWN (8-30%)
cardiovascular risk
CARDIOVASCULARRISK
  • INCREASED
    • SERUM LIPIDS
    • HOMOCYSTEINE
    • C-REACTIVE PROTEIN
    • CORONARY HEART DISEASE
    • HYPERTENSION
    • ISCHEMIC HEART DISEASE
    • ENDOTHELIAL DAMAGE
    • COAGUABILITY
    • PERIPHERAL ARTERY DISEASE
  • DECREASED
    • STROKE VOLUME
    • CARDIAC OUTPUT

MARKERS OF

SUDDEN DEATH

RISK

diabetes risk
DIABETES RISK
  • DISRUPTION OF GLP-1 SIGNALLING
  • DECREASED THYROID FUNCTION UP TO 18 HOURS AFTER HYPOGLYCEMIC EPISODES
  • ASSOCIATED WITH INSULIN RESISTANCE

INCREASED

  • HOMA AND TRIG/HDL
  • DYSGLYCEMIA
  • OBESITY
arthritis inflammation
ARTHRITIS & INFLAMMATION
  • INCREASED RATES OF HASHIMOTO’S
  • INCREASED EUTHYROID SICK RISK
  • RA PATIENTS WITH SUBCLINICAL HYPOTHYROID HAD DYSFUNCTIONS OF GLUCOSE METABOLISM AND INSULIN RESISTANCE
neuro psychological risk
NEURO-PSYCHOLOGICAL RISK

INCREASED

  • HOFFMAN’S SYNDROME
    • WEAKNESS AND STIFFNESS
  • DUPUYTREN’S CONTRACTURE
  • CARPAL TUNNEL SYNDROME
  • POLYMYOSITIS-LIKE SYNDROME
  • PARKINSONS
  • HEARING LOSS
  • ANXIETY AND DEPRESSION
  • 1.97 RELATIVE RISK OF COGNITIVE DECLINE (ALZHEIMER’S)
bone risk
BONE RISK

INCREASED

  • BONE RESORPTION IN HYPERTHYROID
    • URINARY PYRIDINOLINE
    • URINARY DEOXYPYRIDINOLINE
    • URINARY CALCIUM
    • SERUM TELOPEPTIDES
  • NO CALCIUM METABOLISM PROBLEMS IN HYPOTHYROID
    • CALCIUM BINDS THYROID

(TAKE THYROID AT LEAST 45 MINS AWAY FROM CALCIUM)

pregnancy
PREGNANCY
  • FERTILITY ISSUES
  • 3 FOLD INCREASE IN PLACENTA PREVIA
  • 2 FOLD INCREASE IN PREMATURE DELIVERY
  • MAY AFFECT MENTATION IN OFFSPRING
    • NOT WELL STUDIED
factors affecting thyroid function
FACTORS AFFECTING THYROID FUNCTION
  • PERIPHERAL CONVERSION OF T4 TO T3
    • HEPATIC, RENAL, MITOCHONDRIAL FUNCTION
    • DECREASED 5’D-1
      • INHIBITED BY IL-1, IL-6
  • TOXIC MATERIALS
    • LEAD, MERCURY
    • PCB
    • FUNGICIDES, ORGANO-CHLORINE INSECTICIDES
  • DRUGS
      • AMIODORONE, ANTI-CONVULSANTS, SALSALATE, LITHIUM
  • MITOCHONDRIAL PROTEIN LEAKAGE
    • UNCOUPLING PROTEIN 3
  • CYTOKINES
    • NF-KAPPA-B
    • TNF-ALPHA
    • IL-1 ALPHA/BETA
  • EUTHYROID SICK SYNDROME IMPAIRS FUNCTION UP TO 60 DAYS FOLLOWING ACUTE SEVERE ILLNESS
vasoactive intestinal peptide and thyroid function
Vasoactive Intestinal Peptide and Thyroid Function
  • VIP exerts action through 2 receptors VPAC1 and VPAC2
    • VPAC1 receptors are in liver, breast, kidney, prostate, ureter, bladder, pancreatic ducts, GI mucosa, lung, thyroid, adipose tissue, lymphoid tissue, and adrenal medulla.
    • VPAC2 receptors are in blood vessels, smooth muscles, the basal part of mucosal epithelium in colon, lung, and vasculature of kidney, adrenal medulla and retina. Also present in thyroid follicular cells and acinar cells of the pancreas.
  • In hypothyroid, there was a 2-fold increase in all peptides derived from VIP, found in the gastric fundus
  • In hypothyroid significant increases of pituitary VIP
  • VIP modulates T3 and T4 (decreases) in any inflammation
de iodinases
DE-IODINASES

BiancoAC, Salvatore D, et al. Biochemistry, cellular and molecular biology,

and physiological roles of the iodothyronine selenodeiodinases. Endocr Rev. 2002

Feb;23(1):38-89.

T4 to T3 CONVERSION

ACTION ON METABOLISM

thyroid receptor phenotypes
Thyroid Receptor Phenotypes

Alkemade A, Vujist CL, et al. Thyroid hormone receptor expression in the human

hypothalamus and anterior pituitary. J Clin Endocrinol Metab. 2005 Feb;90(2):904-12.

T4 to T3 Conversion

Action on Metabolism

tsh regulation
TSH- REGULATION

MAY NOT REPRESENT METABOLIC DEMAND

nutrients and thyroid
NUTRIENTS AND THYROID
  • SELENIUM
    • IMPROVES FUNCTION DECREASES RECOVERY TIME IN EUTHYROID SICK SYNDROME
  • IRON AND ZINC
    • INCREASE THYROID FUNCTION IN IRON/ZINC DEFICIENT
    • NO EFFECT IN IRON/ZINC SUFFICIENT
  • CALCIUM
    • INHIBITS ABSORPTION
  • ALPHA-TOCOPHEROL
    • NO EFFECT
  • KELP AND ALL IODINE
    • HELPFUL IN IODINE DEFICIENT
    • DOSE DEPENDENT DECREASE IN THYROID FUNCTION IF IODINE SUFFICIENT
  • L-CARNITINE DECREASESTHYROID FUNCTION
    • PREVENTS THYROID HORMONE ENTRY INTO NUCLEUS OFCELLS
  • High Soy intakeinhibits thyroid function
    • Ipriflavone helps bone resorption but does not increase cancer risk
lithium and thyroid function
Lithium and Thyroid Function
  • Enters thyrocyte via the Na+/I- Symporter
  • Concentrated in thyroid gland to 3-4 times serum levels
  • Increases intra-thyroidal iodine content
  • Inhibits coupling of iodotyrosine residues
  • Decreases colloid droplet formation
  • Inhibits microtubule formation
  • Inhibits thyroid hormone secretion
  • Blocks iodine release from thyroid gland
  • Treats hyperthyroid in people allergic to iodine
iodine uptake and retention
Iodine Uptake and Retention

Symporter

Iodine, Lithium

(Retention)

mitochondria

ATP

I-

I-

I-

Thyroid peroxidase

H2O2

TSH Iodine

(trapping)

TG

Proteolysis

T4 T3

Iodinated TG

Colloid Resorption

T4

ECF

Colloid

T3

slide23

HPT AXIS

HPA AXIS

STRESS

HYPOTHALAMUS

HYPO

HYPER

HYPOTHALAMUS

TRH

ZINC

CRH

CRH

ADAPTOGENS

INHIBITS

SNS

PITUITARY

PITUITARY

TSH

ACTH

ACTH

INHIBITS

THYROID

SELENIUM, VIT D

IODINE +/-

ADRENAL CORTEX

MEDULLA

SELENIUM, ZINC, VIT E,

ASWAGANDA

RT3

T4

INHIBITS

GLUCOCORTICOIDS

(CORTISOL)

GLUCOCORTICOIDS

(CORTISOL)

5’DEIODINASE

T3

CATECHOLAMINES

(EPINEPHRINE, NOREPINEPHRINE, ALDOSTERONE)

Hypercortisolemia Inhibits Thyroid Function

influence of other hormones on thyroid activity
Influence of Other Hormones on Thyroid Activity

HERTOGHE, T; The Hormone Handbook. International Medical Books

Surrey, UK, 2006, p88.

hypothyroid causes adrenal dysfunction
Hypothyroid Causes Adrenal Dysfunction
  • Results in hypersecretion of CRH and AVP from hypothalamus
  • Significantly increased pituitary content of VIP
  • ↓ Adrenal weight, ↓ Corticosterone
  •  ACTH, CRH, AVP

Tohei A. Studies on the functional relationship between thyroid, adrenal and gonadal hormones. J Reprod Dev 2004 Feb;50(1):9-20.

measurements of thyroid function
MEASUREMENTS OF THYROID FUNCTION

SERUM MEASUREMENTS

    • What’s on the shelves at the pharmacy
    • TSH INSENSITIVE WHEN APPROACHING NORMAL

PHYSIOLOGIC MEASUREMENTS

    • What you took home from the pharmacy
  • BODY MASS INDEX
    • CORRELATION WITH RESTING METABOLIC RATE
  • BASAL BODY TEMPERATURES
    • IDENTIFY SUBCLINICAL HYPOTHYROID
    • TOO SLOW TO RESPOND TO TREATMENT
  • RESTING METABOLIC RATE
    • SOME ARTIFACTS
      • CONGESTION
      • REACTIVE AIRWAY DISEASE
      • ASTHMA OR OTHER COPD
  • REFLEXES
    • ACHILLES, BRACHIORADIALIS, STAPEDIAL
    • NO ARTIFACTS UNLESS NERVE DAMAGE
methodology
METHODOLOGY
  • ENTRY CRITERIA
    • BBT<97.50 F AXILLARY AVERAGE (BRODA BARNES)
  • BASELINE MEASUREMENT AND THIRTY DAY TREATMENT INTERVALS
    • SYMPTOM SURVEY
    • BODY MASS INDEX
    • RESTING METABOLIC RATE (oxygen consumption)
    • BRACHIORADIALIS REFLEXOMETRY (mean of 4)
    • TSH,T3U, T4, T7
      • ADDED FREE T3, FREE T4
      • SOME HAD
        • MICROSOMAL (TPO) AB
        • THYROGLOBULIN AB
        • REVERSE T3
        • THYROTROPIN RELEASING HORMONE
    • LIPIDS
      • CHOLESTEROL
      • LDL
      • HDL
      • TRIGLYCERIDES
slide28

RESTING METABOLIC RATE

MEASUREMENT VIA OXYGEN

CONSUMPTION

slide30

INCLUDES

COMPUTER

Hammer

Link

Inclinator

slide31

Hammer Strike

Pre-fire

Interval

Fire

Interval

Euthyroid

slide32

Pre-Fire

Fire

HYPOTHYROID

slide33

Prefire Interval

Fire Interval

Hyperthyroid

kail waters equation
KAIL-WATERS EQUATION

RMR = 2307.62 + [-7.53(CM)] + [27.09(KG)] + [-42.59(BMI)] + [-45.47(PREFIRE)] + [45.85(FIRE)] +

[-46.27(FIRE-PREFIRE)]

why tsh does not identify those at risk
WHY TSH DOES NOT IDENTIFY THOSE AT RISK !!!

TSH gets too low before adequate effect (RMR)

Patients that became normal by reflexes and symptoms had a mean RMR increase of about 400 kcals

N=100

TSH <0.3

FIRE-PREFIRE<66

slide43

<0.3 n = 109

0.3-0.5 n = 5

0.5-4.5 n = 146

>4.5 n = 22

sensitivity
SENSITIVITY

Sensitivity is the proportion of those that are hypothyroid that are correctly diagnosed.

It is expressed as:

________True Positives_______ = __117__ = 0.992

True Positives + False Negatives 117 + 1

specificity
SPECIFICITY

Specificity is the proportion of those that are euthyroid that were correctly identified.

It is expressed as:

________True Negatives_______ = ___58___= 0.906

True Negatives + False Positives 58 + 6

predictive value of positive test
PREDICTIVE VALUEof POSITIVE TEST

Predictive Value of a Positive Test is the proportion of those with a positive test that are hypothyroid.

It is expressed as:

________True Positives_______ = ___117__= 0.951

True positives + False Positives 117+6

predictive value of negative test
PREDICTIVE VALUEof NEGATIVE TEST

Predictive Value of a Negative Test is considered the proportion of those with a negative test who are euthyroid:

It is expressed as:

_______True Negatives_______ = ___58____= 0.983

False Negatives + True Negatives 1 + 58

how to optimize thyroid activity and treatment
HOW TO OPTIMIZE THYROID ACTIVITY AND TREATMENT

HERTOGHE, T; The Hormone Handbook. International Medical Books

Surrey, UK, 2006, p87.

homeo and rmr
HOMEO AND RMR

Had to consume too many doses per day to maintain effect

n=5

n=5

n=2

n=1

otc thyroid and rmr
OTC THYROID AND RMR

Had to consume too many doses to maintain effect

n=4

n=3

n=5

tissue and cofactors and rmr
TISSUE AND COFACTORS AND RMR

KELP

IODINE

n=4

n=7

n=3

n=6

n=1

prefire normal
PREFIRE NORMAL

1STVD= 20.72

N = 281

Normal 70-153

fire normal
FIRE NORMAL

1 STVD = 26.80

N = 281

NORMAL 152-259

fire prefire normal
FIRE-PREFIRE NORMAL

1 STVD = 21.24

N = 281

NORMAL 52-137

reflex parameters
REFLEX PARAMETERS

n=281

n=101

n=281

n=14

hyperthyroid signs
HYPERTHYROID SIGNS
  • PALPITATIONS 6:815 0.7%
  • TACHYCARDIA 4:815 0.4%
  • SHAKEY/HYPER 2:815 0.2%
  • HAIR LOSS 1:815 0.1%
  • HYPERTENSION 1:815 0.1%
  • TOTAL 14:815 1.7%
slide68
TSH

< 66 msecs

52-137 msecs

hashimoto s and rmr
HASHIMOTO’S AND RMR

ANTIBODIES STILL HIGH

30 DAYS AFTER

hashimoto s and tsh
HASHIMOTO’S AND TSH

ANTIBODIES NOT RECOGNIZING

(BINDING) NEW MED

ANTIBODIES STILL HIGH

30 DAYS AFTER

thyroid effects on serum lipids
THYROID EFFECTS ON SERUM LIPIDS

SIMILAR TO A STATIN DRUG

N=30

adapting thyroid dose to environment
ADAPTING THYROID DOSE TO ENVIRONMENT

HERTOGHE, T; The Hormone Handbook. International Medical Books

Surrey, UK, 2006,p89.

cost of thyroid meds
COST OF THYROID MEDS

Many on synthetic thyroid require both T3 and T4

Combination Therapy $82.60 for 30 day supply

thyroid myths
THYROID MYTHS
  • DOES SUBCLINCAL HYPOTHYROID NEED TO BE TREATED ?
    • HEALTH RISK IS HUGE IF UNTREATED
  • IS TSH THE BEST CLINICAL MARKER ?
    • INSENSITIVE NEAR NORMAL
      • GETS TOO SMALL BEFORE FULL CLINICAL EFFECT
    • RECEPTOR ACTIVITY DOESN’T REFLECT METABOLIC DEMAND
  • IS IODINE GOOD FOR THYROID FUNCTION ?
    • DECREASES THYROID FUNCTION IF NOT DEFICIENT
  • ARE SYNTHETIC THYROID MEDS MORE PRECISE AND MORE SCIENTIFIC THANNATURAL ?
    • NATURAL THYROID IS BIOIDENTICAL, U.S.P. AND HAS > EFFECT
    • HALF-LIFE IS LONG IN MOST THYROID MEDS
    • MOST PEOPLE END UP ON 2 SYNTHETIC MEDS
      • IF SYNTHROID ALONE CAN’T CONVERT T4 TO T3
      • IF CYTOMEL ALONE T4 GOES TO ZERO
ad